What is the most appropriate management for a 23-year-old woman presenting with a 3-day history of nausea, vomiting, diarrhea, and fever, who is able to keep down some liquids and has normal physical examination findings, including good skin turgor?

Management of Acute Gastroenteritis in a Young Adult with Good Hydration Status

The most appropriate management for this 23-year-old woman with acute gastroenteritis is discharge home on clear liquids with outpatient follow-up. This patient has maintained adequate hydration despite her symptoms, making hospital admission unnecessary.

Assessment of Hydration Status

The patient presents with several key findings that support outpatient management:

• Good skin turgor (indicating adequate hydration)
• Ability to tolerate some oral liquids
• Normal physical examination findings
• Young age without comorbidities

These factors classify her case as "uncomplicated" according to clinical practice guidelines 1.

Management Algorithm

Step 1: Classify Severity

• Uncomplicated: Grade 1-2 diarrhea/vomiting without complicating factors
  • Patient has normal physical exam and good skin turgor
  • No signs of dehydration or hemodynamic instability
  • Able to tolerate some oral intake

Step 2: Provide Appropriate Hydration Instructions

• Recommend 8-10 large glasses of clear liquids daily 2
• Focus on electrolyte-rich fluids (sports drinks) during recovery phase 1
• Gradually reintroduce solid foods as symptoms improve

Step 3: Dietary Modifications

• BRAT diet (Bananas, Rice, Applesauce, Toast) initially
• Small, frequent meals
• Avoid lactose-containing products, alcohol, and high-osmolar supplements 2
• Separate liquids from solids (wait 30 minutes between) 2

Step 4: Symptomatic Medication Management

• Loperamide for diarrhea: 4 mg loading dose followed by 2 mg after each loose stool (maximum 16 mg/day) 2
• Continue until 12-hour diarrhea-free interval achieved
• Antiemetics as needed (e.g., ondansetron 4-8 mg orally) for nausea/vomiting 2

Step 5: Patient Education and Follow-up

• Warning signs requiring immediate medical attention:
  • Inability to tolerate oral fluids for >24 hours
  • Signs of dehydration (dizziness, decreased urination, lethargy)
  • Worsening symptoms or development of high fever
  • Bloody stools
• Schedule outpatient follow-up in 2-3 days if symptoms persist

Evidence-Based Rationale

The Practice Guidelines for the Management of Infectious Diarrhea emphasize that patients with adequate hydration status and without signs of significant volume depletion can be safely managed as outpatients 1. This approach is supported by the American College of Surgeons and American Society of Clinical Oncology recommendations for managing uncomplicated diarrhea 2.

For patients with acute gastroenteritis who can maintain hydration, oral rehydration therapy is not only effective but "less painful, safer, less costly, and superior to administration of IV fluids" 1. Hospital admission would be indicated only if the patient showed signs of dehydration, severe electrolyte abnormalities, or inability to maintain oral intake.

Common Pitfalls to Avoid

1. Unnecessary hospitalization: Admitting patients with good hydration status increases healthcare costs and exposes them to hospital-acquired infections without providing additional benefit.

2. Overuse of IV fluids: When oral rehydration is possible, IV fluids should be reserved for patients with significant dehydration.

3. Premature use of antibiotics: Antibiotics are not indicated for uncomplicated viral gastroenteritis and may worsen the condition by disrupting gut flora 2.

4. Inadequate follow-up instructions: Patients should be clearly informed about warning signs that would necessitate return to medical care.

This approach optimizes patient outcomes while utilizing healthcare resources appropriately, focusing on the patient's demonstrated ability to maintain hydration despite her symptoms.